Navigating Complexity: A Road Map for Successful Transitions Across the Care Continuum September 9-10, 2013

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1 UNIVERSITY OF UTAH DIVISION OF GERIATRICS 30 N E., AB193 SOM SALT LAKE CITY, UT NON PROFIT ORG US POSTAGE PAID SALT LAKE CITY UT PERMIT # th Annual Rocky Mountain Geriatrics Conference Navigating Complexity: A Road Map for Successful Transitions Across the Care Continuum September 9-10, 2013 Snowbird Ski and Summer Resort Salt Lake City, Utah Presented By: Division of Geriatrics, University of Utah School of Medicine In Affiliation With: Center on Aging, University of Utah Geriatric Research, Education and Clinical Center (GRECC VISN 19) VA Salt Lake City Health Care System VA Office of Rural Health Utah Geriatrics Society Intermountain Healthcare, Intermountain Medical Center Department of Medicine and Geriatrics Division Agency for Healthcare Research and Quality (AHRQ)

2 P r o g r a m O v e r v i e w Conference information and online registration are available here: Navigating Complexity: A Road Map for Successful Transitions Across the Care Continuum The Rocky Mountain Geriatrics Conference is jointly produced by the Division of Geriatrics, University of Utah School of Medicine, and the VA Salt Lake City Geriatric Research, Education and Clinical Center (GRECC). Each year this nationally attended conference features a different geriatrics topic to explore in depth. This year s conference theme focuses on successful transitions of care among older adults. Conference Focus: Significant fragmentation of care exists in the United States and is especially burdensome for older adults who are often most vulnerable as they shift across different care locations. Poorly executed care transitions often result in added risk for medical complications, decreased quality of life, and overuse of acute healthcare services (National Transitions of Care Coalition, 2010). Evidence suggests that the activities necessary to conduct safe transitions of care often do not occur, especially in hospitals, emergency departments and nursing homes. Interventions designed to improve transitional care have improved health outcomes among older adults, including reducing hospital readmission rates and decreased rates of adverse events such as medication errors. This conference will explore models of care that are effective in improving patient and family-centered transitions. Target Audience: Content for this conference is appropriate for all professionals who care for older adults. We welcome physicians, social workers, nurses, pharmacists, psychologists, and chaplains. We also welcome health care policymakers, hospital administrators, community care coordinators and others interested in transitions of care. PROGRAM OBJECTIVES: By the conclusion of the conference participants should be able to: 1. Identify best practices in transitional care. 2. Integrate transitional care models into current medical home models. 3. Apply transitional care insights to the long-term care setting. 4. Demonstrate approaches to assess risk for hospital, emergency department, and nursing home readmission. 5. Enhance skills to improve patient and family engagement in care coordination during transitions.

3 Y o u r H o s t H o t e l a n d r C o n f e r e n c e C e n t e r 9500 E. Little Cottonwood Canyon Rd, Highway 210, Snowbird, UT Toll free reservation line of , lodging@snowbird.com Website: PARKING FOR CONFERENCE: Parking for the Snowbird Center is located in Entry #2. PARKING FOR LODGING: Parking for the Lodge at Snowbird is located in Entry #3. If that lot is full, parking can also be found in Entry #2. Please observe signage regarding overnight parking. PERENNIAL AWARD WINNER: Snowbird and its neighbor Alta are perennial favorites for skiers, riders and publications around the world. Alta/Snowbird was named the #1 ski destination in North America in 2008 by Outside Magazine, and both resorts topped SKI and SKIING magazine categories for powder. Snowbird has also received many accolades for its environmental efforts, including the Golden Eagle Award for Overall Excellence and the Utah Earth Day Award for an environmental cleanup project in American Fork Canyon. ACCESSIBILITY: Snowbird is 29 miles from Salt Lake City International Airport with more than 600 daily non-stop flights from most major U.S. cities and 25 miles from downtown Salt Lake City, and is a scenic 45-minute drive from the airport. ELEVATION: 11,000 feet. Snowbird s base elevation at the Lodge at Snowbird is 8,100 feet. Snowbird s highest point is Hidden Peak at ACCOMMODATIONS: A block of rooms is being held at the Lodge at Snowbird for arrival on September 9, Snowbird will accept extended stays at the same rate, based on availability. RESERVATION METHOD: Individuals Call-in - Guests will make own lodging reservations directly with Snowbird s Central Reservation Office by calling or by ing lodging@snowbird.com. Reference the Rocky Mountain Geriatrics Conference, or use group #RMGC13. The rooms are held at our Lodge at Snowbird. Also based on availability, group rates may be extended to additional reservations that exceed the room block. Reservation deadline for this room block is August 9, After the reservation deadline, Snowbird will offer alternate room types from remaining inventory which may require a higher rate. LODGING DEPOSIT: A one-night deposit per room is required at the time the reservation is made, balance auto billed to credit card 3 days prior to arrival date. Full payment is required prior to departure. The room rate is the prevailing Federal Government rate plus local taxes. The current rate is $96.00 single, $ double (subject to change per the prevailing federal per diem rate). Additional rates apply for other occupancy. LODGING CANCELLATION: Lodging cancellation is due 3 days prior to the scheduled arrival date, or the entire one night lodging deposit will be forfeited. No-shows and early departures are considered a cancellation. CHECK IN/OUT: Check-in time begins at 4:00 p.m. and is guaranteed by 6:00 p.m. Check-out time is 11:00 a.m. Luggage storage is available through bell service for guests arriving prior to check-in time and for those involved in meetings or activities that extend past check-out time. RESORT FEE: WAIVED. Complimentary amenities include fitness room, high-speed wireless internet in guest rooms and public areas, USA Today, hot beverage service in lobby, self parking, 800 number phone calls, incoming and outgoing faxes and 15 minutes of daily computer internet usage at the business center. A portion of the resort fee is matched by a congressional grant through the National Forest Foundation, funding local organizations as the Cottonwood Canyons Foundation. AIRPORT TRANSPORTATION: Several transportation companies offer non-stop shuttles from Salt Lake City International Airport to Snowbird s front door. Airport shuttles may be arranged through Snowbird Central Reservations ( ) up to 48 hours prior to arrival. Current round trip pre-paid price is $72.00 per person, plus driver gratuity. Prices subject to change. Walk-ups are accepted on a space available basis at the Canyon Transportation desk located in the baggage claim area of the Salt Lake City International Airport. Cancellations received within 48 hours of arrival are non-refundable.

4 P r o g r a m S c h e d u l e Monday, September 9, :00-8:00 a.m. Registration 7:00-8:00 a.m. Breakfast Buffet 8:00-9:00 a.m. Keynote address: The Bridge to Tomorrow: Best Practices in Care Transitions Stefan Gravenstein, MD, MPH, MA, CMD, FACP, AGSF 9:05-9:45 a.m. Lecture: Transitions Management within the Patient-Centered Medical Home Timothy W. Farrell, MD; Stephanie Wallace, RN, BS 10:00-10:15 a.m. Video and Discussion: Patient-Centered Medical Home Timothy W. Farrell, MD 10:15-10:55 a.m. Lecture: Transitions and Systems Dynamics Andrada Tomoaia-Cotisel, MPH, MHA 11:00-11:30 a.m. Lecture: G-HELP Transitions Program Philip A. Kithas, MD, PhD 11:35-12:10 p.m. Panel Discussion: Transition Between Hospital and Home MODERATOR: Timothy W. Farrell, MD PANELISTS: Stefan Gravenstein, MD, MPH, MA, CMD, FACP, AGSF; Philip A. Kithas, MD, PhD; Karen M. Gunning, PharmD, BCPS, FCCP; Marilyn Luptak, PhD, MSW 12:10 p.m-1:10 p.m. Lunch Buffet 1:10-2:10 p.m. Keynote Plenary: The Enhanced Discharge Planning Program: Innovation and Practice Change in Care Madeleine Rooney, MSW, LCSW 2:15-2:50 p.m. Interactive Discussion: Community-based, Culturally Conscious Supports During Transitions MODERATOR: Marilyn Luptak, PhD, MSW PANELISTS: Madeleine Rooney, MSW; Stefan Gravenstein, MD, MPH 3:05-4:35 p.m. Lecture and Large Group Activity: Motivational Interviewing: Promoting Intrinsic Motivation and Decreasing Resistance to Changing Health-Related Behaviors Brad W. Lundahl, PhD, LCSW, LP 4:35-5:05 p.m. Session Summary: Review and Evaluations Timothy W. Farrell, MD 5:05 p.m. Adjourn Continued on next page

5 P r o g r a m S c h e d u l e c o n t i n u e d Tuesday, September 10, :00-8:00 a.m. Breakfast Buffet 8:00-9:00 a.m. Keynote Plenary: Transitions in the Long Term Care Setting Heather M. Young, PhD, RN, FAAN 9:05-9:40 a.m. Panel Discussion: Transition between Hospital and Skilled Nursing Facility MODERATOR: Timothy W. Farrell, MD PANELISTS: Heather M. Young, PhD, RN, FAAN; Carole Baraldi, MD; Linda McGraw, RN, RAC-Ct; Peter P. Taillac, MD 9:45-10:15 a.m. Lecture: Transitions and Cognitive Impairment Kevin Duff, PhD, ABPP 10:30-11:10 a.m. Lecture: Information Needs and Information Paradigms in Care Transitions Iona M. Thraen, ACSW, PhD; Charlene Weir, PhD, RN 11:15-11:55 a.m. Lecture: POLST Goes Digital in Utah: Introduction to the epolst Peter Taillac, MD 12:00-12:35 p.m. Panel Discussion: Transitions at the End of Life MODERATOR: Shaida Talebreza, MD PANELISTS: Carole Baraldi, MD; Katherine P. Supiano, PhD, LCSW; Peter P. Taillac, MD 12:35 p.m-1:35 p.m. Lunch Buffet 1:35-2:35 p.m. Keynote Plenary: Transitions and Information Technology David A. Dorr, MD, MS 2:40-3:20 p.m. Lecture: Health Economics of Care Transitions Norman J. Waitzman, PhD 3:35-4:10 p.m. Interactive Panel Response to Audience Questions : Navigating Complexity: Reflections on Transitions in Health Care Systems Where Do We Go from Here? MODERATOR: Timothy W. Farrell, MD PANELISTS: Plenary speakers (Gravenstein, Rooney, Young, Dorr); Cherie P. Brunker, MD; Mark A. Supiano, MD 4:10-4:40 p.m. Wrap-up, Session Summary: Review and Evaluations Timothy W. Farrell, MD 4:40 p.m. Adjourn

6 C o n f e r e n c e F a c u l t y Guest Faculty David A. Dorr, MD, MS - Assistant Professor of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University School of Medicine Stefan Gravenstein, MD, MPH, MA, CMD, FACP, AGSF - University Hospitals; Professor of Medicine, Case Western Reserve University; Adjunct Professor of Medicine and Health Services Policy and Practice, Brown University; Clinical director, Healthcentric Advisors Madeleine Rooney, MSW, LCSW - Manager, Transitional Care-Health and Aging, Rush University Medical Center Heather M. Young, PhD, RN, FAAN - Associate Vice Chancellor for Nursing, UC Davis Dean and Professor, Betty Irene Moore School of Nursing at UC Davis University & VA Faculty Carole Baraldi, MD - Assistant Professor, University of Utah Division of Geriatrics; Medical Director, Emeritus Skilled Nursing Facility, Salt Lake City, Utah Philip A. Kithas, MD, PhD - Associate Professor, Division of Geriatrics, University of Utah School of Medicine; Section Chief, VA Geriatric Clinics Brad W. Lundahl, PhD, LCSW, LP - Associate Professor, College of Social Work, University of Utah Linda McGraw, RN, RAC-Ct - Director of Nursing, Emeritus Skilled Nursing Facility Katherine P. Supiano, PhD, LCSW - Associate Professor, University of Utah College of Nursing Peter P. Taillac, MD - Associate Professor (Clinical), Emergency Medicine, University of Utah School of Medicine Shaida Talebreza, MD - Assistant Professor, Division of Geriatrics, University of Utah School of Medicine; Medical Director, Haven HealthCare Home Health and Hospice Iona M. Thraen, ACSW, PhD - Patient Safety Director, Utah Dept of Health; Associate Instructor, College of Social Work, University of Utah; Andrada Tomoaia-Cotisel, MPH, MHA - Research Associate, Department of Family and Preventive Medicine, University of Utah; Doctoral candidate, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine Norman J. Waitzman, PhD - Professor, Dept of Economics Co-Director, Health Society and Policy Program University of Utah Stephanie Wallace, RN, BS - Transitions Navigator, Department of Family and Preventive Medicine, University of Utah Steering Committee Timothy W. Farrell, MD - Assistant Professor of Medicine and Adjunct Assistant Professor of Family Medicine, University of Utah School of Medicine; Conference Chairman Cherie P. Brunker, MD - Associate Professor, Division of Geriatrics, University of Utah School of Medicine; Medical Director, Utah State Veterans Nursing Home Kevin Duff, PhD, ABPP - Associate Professor, Department of Neurology, University of Utah Karen M. Gunning, PharmD, BCPS, FCCP - Associate Professor of Pharmacotherapy & Family and Preventive Medicine, University of Utah Marilyn Luptak, PhD, MSW - Associate Professor and Chair, MSW Aging Concentration; Hartford Geriatric Social Work Faculty Scholar ( ); Spafford Endowed Chair in Social Work ( ), University of Utah College of Social Work Mark A. Supiano, MD - Goodman Family Professor of Geriatrics; Chief, Division of Geriatrics, University of Utah School of Medicine; Director, VA Salt Lake City Geriatric Research, Education and Clinical Center; Executive Director, University of Utah Center on Aging Charlene R. Weir, PhD, RN - Associate Director for Education and Evaluation, VA Salt Lake City GRECC VISN 19; Associate Professor, Biomedical Informatics, University of Utah; Investigator, VA Salt Lake City IDEAS Center Karey A. Johnson, DNP, RN - Director, Northwest Region Center of PACT Excellence; Manager, Center for Learning Excellence; Associate Chief for Nursing Service/Education VA Salt Lake City Health Care System Jack Christensen, BS - Education Specialist, VA Salt Lake City GRECC VISN 19

7 R e g i s t r a t i o n I n f o r m a t i o n Registration Fees Early Bird Received after Registration Aug 9, 2013 Physicians (All) $375 $425 Non-Physicians 1 $250 $300 Students and Trainees 2 $125 $175 1 Includes all who are not Physicians. 2 Includes undergraduate and graduate students, residents and fellows. Secure and Easy to Register: Register Early Register online...use our secure server at: (credit card payment only) Fees include continental breakfasts, lunch, refreshments, syllabus materials, and accreditation certificates. All fees are due in advance; registrations will not be processed without payment. Your registration will be confirmed by at time of registration. If confirmation is not received, please contact (801) ; Valerie.Horton@hsc.utah.edu Cancellation Policy: Cancellation of registrations must be received in writing no later than September 2 nd. All fees paid will be refunded, minus a $50 processing fee, for cancellations received before August 9 th. Between August 9 th and September 2 nd they will be subject to a $100 processing fee. No refunds will be issued after September 2 nd for cancellations or noshows. Substitutions are permitted if requested in writing. Please fax cancellation or substitution requests to (801) The conference committee reserves the right to cancel this conference in the event of unforeseen circumstances or if the minimum acceptable registration is not met. In the event of conference cancellation, registration fees will be refunded. Online Registration Contact: Valerie Horton; (801) Valerie.Horton@hsc.utah.edu Division of Geriatrics, 30 N E., AB193 SOM, Salt Lake City, UT For Multiple Attendees on Same Credit Card or for Alternate Registration Method, Contact: Jack Christensen, for more information, at (801) x2435, or your request to Jack.Christensen@utah.edu A c c r e d i t a t i o n Accreditation: The University of Utah School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. AMA Credit: The University of Utah School of Medicine designates this live activity for a maximum of 14 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity. ANCC - This activity has been submitted to the Utah Nurses Association for approval to award contact hours. The Utah Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. NASW - This activity has been submitted for 14 CEU credit hours. AAFP - Prescribed credits by the American Academy of Family Physicians. Have been applied for and are pending. AGS GRA - This CME activity is endorsed by the American Geriatrics Society. Credits earned from this activity may be counted toward the AGS Geriatrics Recognition Award. Accreditation updates will posted on the conference website. Nondiscrimination and Disability Accommodation Statement: The University of Utah does not exclude, deny benefits to or otherwise discriminate against any person on the basis of race, color, national origin, sex, disability, age, veteran s status, religion, gender identity/expression, genetic information, or sexual orientation in admission to or participation in its programs and activities. Reasonable accommodations will be provided to qualified individuals with disabilities upon request, with reasonable notice. Requests for accommodations or inquiries or complaints about University nondiscrimination and disability/access policies may be directed to the Director, OEO/ AA, Title IX/Section 504/ADA Coordinator, 201 S President s Circle, RM 135, Salt Lake City, UT 84112, (Voice/TTY), (Fax). Please contact Jack Christensen, for more information, at x2435 or your question to Jack.Christensen@utah.edu

8 Call for Exhibitors for the 11th Annual Rocky Mountain Geriatrics Conference We have vendor/exhibitor display opportunities available for this great conference. Healthcare Industry and Organization representation at this event in the past has been a valuable addition for our participants. The Rocky Mountain Geriatrics Conference is jointly produced by the Division of Geriatrics, University of Utah, and the VA Salt Lake City Geriatric Research, Education and Clinical Center (GRECC). Each year this nationally attended conference features a different geriatrics topic to explore in depth. This year s conference theme focuses on successful transitions of care among older adults. Take the opportunity to present your company/organization to a great national group of medical care professionals. To arrange for space, or if you have questions, you can contact Jack Christensen, ex2435, or ; Jack.Christensen@utah.edu See You In September!! Directions to Snowbird from the Airport, Downtown, Points South & Park City Snowbird is only 25 miles (30 minutes) from downtown Salt Lake City and 29 miles (40 minutes) from Salt Lake City International Airport. From the Airport take I-80 East to I-215 South. Take Exit 6 (6200 South) and go east on 6200 South, toward the mountains. This road will lead you straight to UT-210 and up Little Cottonwood Canyon to Snowbird. From Downtown Salt Lake City take 500 South west to I-15 and head south. Exit at I-215 heading east. Get off at Exit 6 (6200 South) and go east on 6200 South, toward the mountains. This road will lead you straight to UT-210 and up Little Cottonwood Canyon to Snowbird. From points south take I-15 north to Exit 295 (9000 South). Turn right onto 9000 South. This street becomes 9400 South, which takes you to the mouth of Little Cottonwood Canyon. Go right on UT-210. It s then about 6 miles up to Snowbird. From Park City take UT-224 west and north to I-80. On I-80, head west toward the Salt Lake Valley. Take Exit 130 to I-215 South. Get off at Exit 6 (6200 South) and go east on 6200 South, toward the mountains. This road will lead you straight to UT-210 and up Little Cottonwood Canyon to Snowbird. For online map/travel info:

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